10 years but little progress on patient safety

Constant readers, I’ve been away for a week — trying to get my breath back now that the chaos of the novel H1N1/swine flu is diminishing — and so I’ve missed a lot of news. Over this week, I’ll try to catch you up on it.

First up: Some of you know that, 10 years ago, the nonpartisan, Congressionally-chartered Institute of Medicine (IOM) published a groundbreaking report called To Err is Human (html here, pdf here) that jump-started examination of medical quality in the United States. That report said:

Health care in the United States is not as safe as it should be–and can be. At least 44,000 people, and perhaps as many as 98,000 people, die in hospitals each year as a result of medical errors that could have been prevented… Preventable medical errors in hospitals exceed attributable deaths to such feared threats as motor-vehicle wrecks, breast cancer, and AIDS. … Beyond their cost in human lives, preventable medical errors exact other significant tolls. They have been estimated to result in total costs (including the expense of additional care necessitated by the errors, lost income and household productivity, and disability) of between $17 billion and $29 billion per year in hospitals nationwide. (To Err is Human, executive summary)

The report prompted a huge groundswell of legislative interest and patient advocacy that led, years later, to the successful passage of state laws insisting on public reporting of hospital infections and more recently on disclosure of hospital-acquired MRSA.

And yet: Despite all that scrutiny and activism, we are nowhere near as far as we should be in reducing medical errors. Just in the area of hospital infections, which is our greatest interest here, there is not mandatory reporting in all states, and there is no nationwide reporting.

Ten years later, we don’t know if we’ve made any real progress, and efforts to reduce the harm caused by our medical care system are few and fragmented. With little transparency and no public reporting (except where hard fought state laws now require public reporting of hospital infections), scarce data does not paint a picture of real progress. Based on our review of the scant evidence, we believe that preventable medical harm still accounts for more than 100,000 deaths each year — a million lives over the past decade. This statistic by all logic is conservative. For example, the Centers for Disease Control and Prevention (CDC) estimates that hospital-acquired infections alone kill 99,000 people each year.

The project finds that many of the reforms recommended by the IOM in 1999 have not been created:

Few hospitals have adopted well-known systems to prevent medication errors and the FDA rarely intervenes.While the FDA reviews new drug names for potential confusion, it rarely requires name changes of existing drugs despite high levels of documented confusion among drugs, which can result in dangerous medication errors. Computerized prescribing and dispensing systems have not been widely adopted by hospitals or doctors, despite evidence that they make patients safer.

A national system of accountability through transparency as recommended by the IOM has not been created. While 26 states now require public reporting of some hospital-acquired infections, the medical error reporting currently in place fails to create external pressure for change. In most cases hospital-specific information is confidential and under-reporting of errors is not curbed by systematic validation of the reported data.

No national entity has been empowered to coordinate and track patient safety improvements.Ten years after To Err is Human, we have no national entity comprehensively tracking patient safety events or progress in reducing medical harm and we are unable to tell if we are any better off than we were a decade ago. While the federal Agency for Healthcare Research and Quality attempts to monitor progress on patient safety, its efforts fall short of what is needed.

Doctors and other health professionals are not expected to demonstrate competency.There has been some piecemeal action on patient safety by peers and purchasers, but there is no evidence that physicians, nurses, and other health care providers are any more competent in patient safety practices than they were ten years ago.

The entire report is well worth reading. Its lamentable but well-supported conclusion:

We give the country a failing grade on progress on select recommendations we believe necessary to create a health-care system free of preventable medical harm.